A community health center located in and serving the five towns of the Mascoma Valley.

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1 What is Mascoma Community Health Center? A community health center located in and serving the five towns of the Mascoma Valley. Where is the health center? It hasn t been built yet. Mascoma Community Healthcare is currently seeking loans for the building and equipment from the United States Department of Agriculture Rural Development program. We anticipate a decision about our application by July of Once we receive the loan approval, the project will go out to bid and construction should start late this fall. The target date for the grand opening is in Look for our sign on Route 4 in Canaan at the intersection o f Roberts Road. This health center is important to all of us. Here are the reasons why. 1. This is the only health center in the immediate Upper Valley that will combine mental health, medical care, pharmacy, lab and dental care in one building with one billing system, one record system and one appointment system. 2. The furthest distance a person will drive is about 9 miles and in little traffic. 3. This clinic is near your home, not just your work. That makes it a healthcare facility for your whole family. 4. The clinic is available in the evening and weekends as well as during the day. 5. The clinic will serve our schools, senior housing, senior center and social service agencies. 6. The health center will take all insurance policies. 7. People with catastrophic insurance policies that cover just hospitals and specialists can have affordable primary care for about $125 a month. 8. People with no coverage will have a sliding scale fee system or lower costs for everyone regardless of income. 9. Employers and individuals can get a community insurance plan that cuts costs up to a third and will still cover hospitals, specialists and care outside of our region. 10. If employers drop health insurance plans or increase deductibles or make you pay thousands of dollars in premium sharing with them, this health center provides an option. 11. It s ours. It s not a for profit corporation. It s not a large institution. There is no distant Board of Directors. No one can take it over or dictate how we get care. We, the patients, manage it. We want you to be part of that management. 12. This is a local solution to get great care, have convenience and affordable coverage. It s being done elsewhere in Vermont and New Hampshire and it can be done here without relying on anyone else to save us. It does need all of us to join in. What types of service are planned for the health center? Family practice, pediatrics, gerontology, behavioral health, community program referrals, dentists, dental hygienists, dental appliances, maternity care, physical therapy, lab services, radiology, education, counseling, nutritionists, pharmacists, and medicines. How many doctors and nurse practitioners will there be? The number of doctors varies depending on patients.

2 With 1600 patients there will be 1.4 doctors and 1 nurse practitioner. With 6,000 patients there would be 3.3 doctors and 3.5 nurse practitioners. In both of these examples, the doctor coverage would be greater than the norm in our area. The number would change as the patient base grows. Where will the doctors come from? Wherever possible, we would try to contract with existing doctors that currently serve our residents. We would try to draw in doctors from Dartmouth Hitchcock, Alice Peck Day and independents. What will the hours be? Will it be open 24 hours a day and weekends? The health center will be open 40 hours per week at the beginning and will expand to least 60 hours a week with at least several evenings a week and Saturdays. It will not be open 24 hours a day but there will be emergency call service 24 hour per day, seven days a week. Do I need to be a resident of one of the five Mascoma towns to use the health center? No. The health center will be open to anyone but its mission is to serve the Mascoma Valley health care needs. Any person may use the health center. Will there be an emergency room? It will not be a trauma center. We will take unexpected or urgent cases. There will be adequate blocks of time reserved every day for unscheduled care. How long will I wait for an appointment? The goal will be to schedule an appointment within a week for non-urgent matters. How does the dental service work? The dental suite will provide examinations, emergency care, rehabilitation, sealants, fillings, cleanings, fluoride treatments, and oral surgery. The health center will have one central scheduling office and one set of receptionists for all services including health and dental. This will allow for appointment coordination and easier communication. What will be offered for radiology? Does it include MRI s? Minor x-rays for quick diagnosis such as broken bones will be done at the clinic but not until there are at least 3,000 patients. Other minor x-rays could include chest or back x-rays that would be evaluated by a regional hospital s radiologist electronically. Major radiology including MRI s will be done at a hospital. Will the health center care for respiratory patients? How about diabetics? Respiratory care and diabetic care are typical in primary care and will be provided. Nebulizer treatments will be done at the health center. Acute cases will be referred to specialists like an endocrinologist or a pulmonologist. Will optometrists and audiologists offer service at the health center? The health center will explore adding optometrists and audiologists to serve on a part time basis as the patient population grows. If I go to the health center, will I still be able to go to my hospital? Yes. The health center is the same as your family doctor but with more services. For specialists or the emergency room or surgery, you would still use your usual hospital or specialists.

3 Can I use Dartmouth Hitchcock or Alice Peck Day? Assuming that your insurance allows either or both, yes. If I see a D-H doctor or APD doctor at the health center, must I use the hospital that the doctor is affiliated with? No. You have the right to ask for a referral to any hospital you choose. Will the health center make referrals? Yes. The health center will make referrals to other specialists and facilities. If I use the health center for my doctor and pharmacy, can I still go somewhere else? Yes. You always have choice. What will a health center visit cost? A typical office visit would be $135 and a lab panel would cost $35. This will be paid by insurance if you have it. There would be no other deductibles or co-pays required unless the insurance doesn t cover the full cost of the visit. If you are required by your insurance company to pay a co-pay and it s more than the visit, we will accept it and refund it. A dentist appointment would be $185 and a cleaning would be $135. X-rays are dependent on service. If you have insurance that pays at least this amount, the cost would be fully funded by the insurance and there would be no additional co-pay. If your insurance requires co-pays, we will do everything we legally can to refund the co-pays. Remember that the health center will have a sliding scale system with reduced charges for those who can t afford regular fees. How does the cost compare with other health centers? People with insurance on the average currently pay $3,676 a year for traditional health insurance coverage for primary care, medicines and dental care. With the new health center, our average per capita cost for care would be less than $1,500. The Plainfield, Vermont Health Center spends about $1, per patient per year (including dental & medicine) with 10,000 patients. The cost at Ammonoosuc Community Health Services with five facilities including Littleton, Warren and Woodsville and 8,500 patients was $1,457 in 2012 (including medicine and dental estimates). The cost at Mid-State Health Center with two facilities in Plymouth and Bristol and 10,000 patients was $1,352 (including medicine and dental estimates). Neither Ammonoosuc nor Mid-State had significant dental programs. Mid-State did not have a pharmacy. How do you know this will work financially? The original business model was based on three health centers that have been in operation for decades. The planning group had Helms & Company, a major health management consultant in Concord, New Hampshire, review the numbers for compensation rates and the staffing levels for the proposed services. Minor adjustments were made and the final organizational chart and budget were finished. Using the actual services delivered in New Hampshire by 10 existing community health centers, we built two proportional models with similar visits and services per person for 1,600 patients and 8,000 patients. We used the 1,600 patient model as our start-up model. We then computed the revenue based on the lowest insurance reimbursement level we could obtain. The result is that we cover all expenses with a surplus of nearly 5%. The actual cost of care would be 49% less than what we currently pay in premiums to the insurance companies. In every case after the first 18 months, the health center covers its costs and reduces payments by patients. How does the health center save money? The health center is non-profit. The health center combines services in one location to reduce duplicated administrative cost including record keeping, billing and scheduling. It is simpler to get lab

4 work and simple x-rays completed. It does not have high institutional overhead that health centers operated by large organizations carry. It maintains a lean, efficient physical plant. Its capital costs are significantly lower. It minimizes malpractice insurance by offering comprehensive quality service that is accountable to the community with fewer mistakes and lawsuits. It offers a wide range of services that keeps patients healthy and minimizes hospital and specialists visits. It doesn t need to advertise to capture market share relying instead on word of mouth and reputation. It can focus on health quality rather than repetitive services. These differences will save at least 40% of the cost of primary health care. The bargaining for the lowest price for medicine and the elimination of middlemen will reduce pharmaceutical costs by more than 70%. Who s funding the health center? The construction will rely on loans and grants from the federal and state governments. We will try to use NH and federal Community Development Finance Authority funding. USDA Rural Development loans will be used to fund the building and equipment. We will be looking for contributions from area businesses for part of the funding. We have secured a great deal of funding already and we hope to complete all funding by the end of All ownership and financing would be done through Mascoma Community Healthcare, a 501(c) 3 non-profit. We will keep all members of the public informed as we move forward. How does the health center answer to me? Law requires that at least 51% of the Board of Trustees of the health center consist of patients who use the center. Can I sign up as a patient at the health center now? You can pledge to give us a try when we open in In fact we need you to. Lenders want to see that we have real people willing to use the health center. A pledge means you will try to use the health center when we open. It does not mean you are obligated to use us. We know we have to earn your trust and respect. How do I sign up? You can sign up by filling in a pledge card to try it. Can I change my mind? Yes. You can change your mind about pledging to use the health center as well as changing your doctor after you join the health center. So, if I don t like the health center can I go back to my former doctor? Yes. You will always have choice. You may also see both your former doctor and the health center. Do I have to have a special insurance policy to go to the Health Center? No. The health center will take any insurance policy from participating insurance companies that reimburse family doctor or primary care services. Can I use Anthem Blue Cross, Harvard Pilgrim, Cigna and MVP? The health center will have participation agreements with all major insurance companies prior to opening. There are a variety of ways that we can accomplish this but it will be a priority before opening. We can t start the process until we know that the health center has at least 1,600 patients.

5 Will the health center take Medicare and Medicaid? Yes. How does the health center work with Affordable Care Act (Obamacare)? Obamacare is a program to guarantee access to health insurance, subsidize the payment of premiums for those least able to pay and assure coverage for people most at risk by removing lifetime caps and exclusions from coverage. The program creates health insurance exchanges that make insurance plans available to individuals that otherwise would pay very high premiums. The health center offers very competitive service that reduces costs for insurance companies and patients. There would be no other deductibles or co-pays required unless the insurance doesn t cover the full actual cost of the visit. If you are required by your insurance company to pay a co-pay and it s more than the visit, we will accept it and refund it. For people getting the least expensive Insurance Exchange policies with high deductibles or for just catastrophic coverage, the health center offers a way to make those plans work by offering primary care at very competitive cost which will stretch deductible dollars. With the prospect of having non-profit cooperative insurance policies offered through the health center by next year, employers will have the real opportunity to save as much as 25% on the premiums. Can I use TRICARE insurance and will the health center cooperate with the Veterans Administration? Yes and yes. Does my dental insurance work at the health center? The health center will negotiate participation agreements with major dental insurance programs. If I have health insurance will it cover my dental care? Most health insurance policies are separate from dental policies. There will be a new cooperative insurance policy available for use with health center that will combine health and dental insurance. What do I do if I don t have insurance? The health center will take direct patient payments. The health center will also offer a fixed annual price for all covered primary care, medicine, behavioral health, physical therapy, and dental care. This low annual price is great for people that currently have high deductibles or catastrophic insurance coverage only. The fixed price coverage would be less than $150 per month. Can I get care if I have no money? Yes. The health center will work with all patients to keep health care affordable. The center will use a sliding scale payment system and help people apply for assistance. Will my care as a low income person be the same as everyone else s care? The quality of care will be uniformly high for everyone regardless of income. I ve heard the health center is planning on offering cooperative non-profit health insurance. Why? There is a large difference between what is spent on insurance premiums and what is paid to doctors and hospitals. Only 82% of the amount we spend on premiums actually goes to a provider. By removing insurance company profits and streamlining reimbursements and capturing primary care and pharmacy savings, there is the potential to save more than 25% of what we currently pay for premiums. Capturing savings is a critical reason for a non-profit insurance plan.

6 How will a cooperative insurance plan help me or my employer who pays the insurance? A cooperative insurance policy will have lower administrative costs and will not be taking profits. According to the NH Insurance Department, 11% of all premiums are used for administrative costs and 8% of premiums go to retained earnings and profit. At a minimum, the cooperative insurance plan should save employers or people paying for their own insurance 8%. This 8% is over and above savings from more efficient service. The health center serving 8,000 patients and working with a nonprofit insurance company can save up to 25%. How do I know that a cooperative insurance plan will work? It is already being used in Massachusetts and is being approved now in New Hampshire. Can I sign up for the cooperative insurance now? No. As soon as the plan is in place we will announce an enrollment period. In New Hampshire there is usually an insurance company acting as a middleman between the private rate payer and patient and the healthcare provider. The New Hampshire Department of Insurance reports on how this relationship works. Generally, the insurance company proposes policies it will offer for sale and sets rates based on what they project the cost to be. If the projections are less than what they projected, they keep the difference or use it for internal purposes. Generally, excess revenues are used to pay shareholder dividends, increase fees for insurance services, increase management compensation or increase reserves (capitalization). Healthcare savings are usually not returned to patients or rate payers. Rates are not reduced when insurance companies pay less. In fact, historically the proposed rates for the following year increase well in excess of the old rates that generated profit in the past year Can I use the cooperative insurance to go to other doctors, specialists, and hospitals? Yes. Typically, the insurance plan includes most hospitals, specialists and primary care providers. There may be higher co-pays for primary care providers who are not in the plan s network. What do I need to do to get the insurance? The co-operative insurance policy is not available yet. It is hoped that the policy will be available soon after the health center opens. What are the co-pays and deductibles with the health center insurance policy? There are no co-pays and deductibles for using the health center and the health center pharmacy. There are co-pays and deductibles for using facilities other than those operated by the health center. Can I be refused insurance or care for pre-existing conditions? No. If I get a health insurance plan from the health center can I go back to my old insurance policy? You will have insurance portability and under the Affordable Care Act you can leave the cooperative policy to sign up with another insurance company. Mascoma Community Healthcare Visit mascomacommunityhealthcare.org

7 Mascoma Community Health Center Visit mascomacommunityhealthcare.org (can be filled out on line!) Yes, I want to see a community health center that offers comprehensive care at a lower cost. I want my health care professionals to listen to me and work for our local communities. I am ready to try the health center in 2016 when it opens. I understand that this pledge to try the health center is non-binding but that the decision to go forward and build the center is based on people like me saying they will try it. First Name: Last Name: (Please print.) Number in my household who would use the health center: Please list all of the ages and genders in your household (i.e. 27-M, 25-F, 3-M) Age & Gender (M-F) Age & Gender (M-F) Age & Gender (M-F) Age & Gender (M-F) Street Address: Town: State: Zip: Telephone Number: address: I have a primary care / family doctor now. Yes No I have insurance now. Yes No Insurance Company Name: Fill out and mail (needs an envelope and stamp) Mail to Mascoma Community Healthcare, PO Box 550, Canaan, NH Rev 5/26/15 We have more than 2,500 pledges now! We would like to reach 3,000 before we open. We need your help. Fill out a pledge. Talk with your friends and neighbors.